Monday, December 12, 2011

The Great Health Reform Picture Show - As Seen Through Medinnovation's Complexity Lens and Physicians' Eyes

The Health System, From Top-Down to Bottom-Up, As Seen Through Lens of Cultural Complexity

Substitle of Book, Obama, Doctors, and Health Reform, 2009

December 12, 2011 - One purpose of this blog, which now has 2064 entries over the last 5 years, is to illustrate the complexity of health reform.

Here I have chosen to show how doctors react to reform's complexity by showing what they are reading in the Medinnovation blog.

What follows are the top ten Medinnovation blogs read by doctors over the last 36 months.

As you read the title of these ten blogs, keep in mind that the Accountable Care Act, aka Obamacare, passed 20 months ago on March 23, 2010. One of these blogs, preceded the ACA, nine occurred after its passage.

1) Is Practice Fusion’s “Free” EHR for Real?

May 23, 2010, 2537 Hits

This is by far most visited blog, by a factor of 2.5:1. The goals of universal physician/hospital EHRs are to document, monitor, control, and decide how to pay for tens of billions of annual patient-doctor-hospital transactions through the miracle of Health Information Technologies.

Achieving these goals is powered by $27 billion federal dollars and complicated by 186 EHR companies vying for the business. Practice Fusion Inc has grown 7-fold to 130,000 physician-users over the last year by simplifying EHR installations, transactions, use, and price. Practice Fusion is just one of these EHR companies. Other EHR firms are also growing rapidly.

Doctors know EHRs are inevitable but are waiting to see how effortlessly, cheaply, effectively, and efficiently they can get on the right side of the Digital Divide without disrupting their practice or losing revenue while still qualifying “meaningful use” bonuses.

2) Interview, physician Shortage - Interview with Richard "Buz" Cooper, M.D., Professor of Medicine at the University of Pennsylvania

Jan 24, 2009,1,194 Hits

This is an interview with “Buz” Cooper, MD, U Penn professor of medicine, who predicted large doctor shortages long before anyone else. In the interview, he gives reasons for the shortage. Cooper says health reform is on a collision course with shortage of doctors. Contrary to popular belief,engendered by Dartmouth Institute that provider greed leads to regional differences in Medicare costs, Cooper believes highest costs occur among poorest patients, whose costs are high care because prevention,diagnosis, and treatment are often neglected until late in disease.

3) Primary Care Revolt: Replace the RUC

Apr 17, 2011, 1107 Hits

This is an under-the-radar account of a revolution going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid. The RUC, Reimbursement Update Committee, or the Relative Value Reimbursement Value Committee, is dominated by specialists. These specialists, say the Primaries, ovwerwhlmingly set Medicare fees for doctors. RUC is a creature of the AMA. CMS endorses its decisions over 90% of the time. Primary care societies claim RUC fee schedule favors specialists and says its list of members should be reconfigured to give primary care specialists more of a voice.

4) The Low Value of Primary Care Doctors in Eyes of Patients

Jul 1, 2010, 971 Hits

Sometimes it is painful to discuss the obvious, especially when the obvious goes against your grain. But here goes. Primary care is in a bad way. Only 2% of medical students are picking primary care specialties. The number of primary care doctors is dropping. And over 90% of costs stem from specialty care. Primary care disarray, unhappiness, and low morale comes from these obvious causes : low reimbursement, long work hours, and as Rodney Dangerfield, might say, “We get no respect.” This in face of the fact that policy types and payers, like IBM, are calling for a rejuvenation of primary care as the salvation of American medicine with its cost, coordination, care improvement, and efficiency problems.

5) The Future of Accountable Care Organizations

Jan 26, 2011, 607 Hits

This was an interview with Bill DeMarco, a health care consultant for more than 30 years and an advisor on Accountable Care Organizations (ACOs). The subject of Accountable Care Organizations (ACOs) accounted for only 10 pages of the 2700 page health reform bill. Yet ACOs were then the buzz, the rage, the hottest 3-letter acronym since sliced bread, and the most talked about subject in hospital board rooms, medical staff lounges, and the medical talk circuit, and consultant enclaves. I am cautiously pessimistic about the future of ACOs. My views on ACOs are available in an e-book , Pros and Cons of Accountable Care Organizations (

6) Comments on Yesterday’s Value (Outcomes/Cost) Blog

Dec 31, 2010, 474 Hits

I posted this blog on the value of measuring outcomes of various diseases based on cost. The Health Care Blog, probably the most widely read of blogs pertaining to health care policies, reran my piece. In my blog,I expressed skepticism about the practicality of value determinations based on outcome measurements on a broad scale across the medical care spectrum. I closed with these questions. Here are the comments from readers of The Health Care Blog.

I ended my blog with these questions.

1. Is overall health care value measurable?

2. Are the organizational, societal, and individual costs required to make this value measurement worth it?

3. Will the measurement of value unify ideological factions competing to advance the cause of health reform?

I had my doubts.

7) Why Doctors Don't Like Electronic Health Records

Oct 7, 2011, 455 Hits

On September 27, 2011, An article of mine appeared in the Technology Review, an MIT Press publication. The Health Care Blog, the most widely read health blog, reran it on October 9, and it immediately drew 26 responses.

Here is the gist of the article.

A physician argues that electronic patient records raise costs, decrease patient visits, and make poor communication tools.

Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal "interoperable health information" infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records. There at least 10 good reasons doctors resist EHR use.

8)Health Reform: Look at Massachusetts First

May 2, 2011, 347 Hits

If you doubt the likely effects of health reform on health care, says Kevin Pho, MD, in its widely-read blog,, "Look at Massachusetts first." In its stab at universal coverage, now four years old, Massachusetts has seen these consequences: overcrowded ERs, longer waiting times to see doctors, more than 50% of primary care doctors closing practices to new patients, and the highest health care premiums in the nation.

So much for lowering health costs and expanding access. And all of this in state with more primary care physicians per capita than any other state, in a state with fewer uninsured than any other state, and in a state with an individual mandate and a health plan said to be a model for Obamacare.

These, of course, all factors in Mitt Romney's baggege as a Republican Presidental candiate. He must explain to conservatives and the public at large the rationale of his support for the individual mandate and why and how Romneycare differs from Obamacare, His answer is that ech state is entitled to its own brand of health care, and the people of Massachusetts like their plan by a 3:1 margin.

9) Accountable Care Organizations (ACOs): California or Bust.

Sept 16, 2010, 1 268 Hits

I am skeptical in this blog about the futue of ACOs.

Why was I skeptical?

I suppose one reason is that I have been down the road before as a founder of the Physician Hospital Care Organization, later the Integrated Care Organization, in the 1990s, both now defunct because of mutual physician-hospital distrust and conflicting competitive goals.

Secondly, California’s business and health care climate, politically and in health care, are not representative of the U.S. as a whole.

Thirdly, California is a budgetary basket case, with a budget deficit of $20 billion.

Fourthly, I am dubious of the Congressional Business Offices estimate that ACOs will save $4.9 billion over 10 years through a limited pilot program.

I may have been wrong, but, given the complexity of the final ACO rules, enthusiasticlly endorsed by CMS administration by CMS Administator Donal Berwick, before Republicans forced his resignation, and almost universal rejection by the hospital, physician, large health system communities, there was room for skepticism.

10) Doing Better and Feeling Worse: Why Aren't Doctors Feeling Better About The Future?

Nov 29, 2010, 231 Hits

Why, if health care will be the next engine of growth and will consume ever more of the GDP, are doctors feeling so glum about the future? If you doubt how they feel, I invite you to read Health Reform and the Decline of Physician Private Practice (Merritt Hawkins. October 2010).

This feeling of dread is not new. In 1977, John Knowles, MD, a Massachusetts General internist who became the President of the Rockefeller Foundation, edited a book Doing Better and Feeling Worse: Health in the United States (W.W. Norton and Company).

The problem then, as now, was the system was doing better in improving health outcomes but doing worse in controlling costs, and many of the bad things, in both the economic and health realms, that happen to people were beyond the reach of medicine. The health system didn’t have all the answers.

To take a leading example, why can’t we contain demand and control health costs?

That, of course, is this year’s $2.7 trillion question - the estimated cost of the ACA from 2014 to 2024.

According to Regina Herzlinger, PhD, a tenured professor at Harvard Business School, the problem is we don’t let consumers, spend their own money. pick their own providers, drive the system.(Who Killed Health Care? America’s $2 Trillion Medical Problem – and the Consumer-Driven Cure (McGraw Hill Companies, 2007).

Dr. Herzlinger identifies the five “killers” of a consumer-driven system as:

1. Health insurers, who insure the death of cost control through their dysfunctional culture.

2. General hospitals, which kill cost-control through their building of centralized. Ever-expanding empires of care.

3. Employers, who doom consumerism because they generally give their employees the “choice” of only one plan.

4. The U.S. Congress, who spur cost growth through lavish entitlement program riddled with fraud, abuse, and overuse.

5. Academics who contribute to the death of consumerism because of their elitist, technocratic, superior attitudes.

“Sadly, “comments Herzlinger, “on the federal government level, representatives from Republicans and Democrats have quaffed deeply form the Beltway Kool-Aid well. Neither believes in the power of innovators and consumers to reshape markets. Neither is in the-small-is-beautiful camp. Both believe the more oversight of health care by the government and academies is the solution. Both believe that big-is-beautiful.”

She goes on, “The federal government has not only specified what should be measured but also the protocols that health care providers must follow. These monopolistic powers are cloaked in the pseudoscientific mantle of ‘evidence-based.” The title implies that the guidelines are shaped by intelligent saints devoid of a shred of self-interest or vanity, guided only by ‘evidence’”

Small wonder doctors are glum. Everyone else, other than themselves and their patients, think they know what is best about the practice of medicine and the health care business. The health reform law effectively squelches health savings accounts which encourage consumers to shop for what they consider to be the best deal and doctors to compete for the consumers’ dollar. Rules and regulations forbid doctors to creatively re-design their practices and repackage their services. Medicare laws prohibit patients and doctors from privately contracting with each other. Prices keeps rising as regulations keep growing.

Medicine, it seems, is too important to be left to doctors and consumers. Trust us, is the mantra. We’re from the government and other large institutions, and only we know what is good for you and yur health.

Tweet: Health reform is fiendishly complex. I offer these 10 most widely read Medinnovation blogs as evidence.


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I have enjoyed reading your articles. It is well written. It looks like you spend a large amount of time and effort in writing the blog. I am appreciating your effort.

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